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My Med School OSCE

Christine Benton Criswell

__________

I knew I was in for it when Allen came out of the exam room. He looked pained.

“It was awful,” he said. “All I can say is … good luck.”

We were participating in our medical school OSCE—the Objective Structured Clinical
Exam. We would interview, examine, and diagnose actor patients. Proctors would grade us, and
if we failed to pass, we would not be allowed to start seeing patients the following year.

I tried to shake off my nerves, knocked on the door, and walked in.

Three people were in the room. The patient was a young woman, sitting on the exam
table, arms crossed, head bent, wearing all black. A severe-looking man in the corner with a
clipboard had to be the proctor. And then there was the middle-aged woman. I still, to this day,
don’t know who she was supposed to be, but she looked like she was in a hurry to get this over
with.

“Hello. I’m Dr. Benton. How are you?” Neither the patient nor the woman responded.

I gave them another couple of seconds. When this failed, I proceeded to wash my hands.
A full twenty seconds, just as I’d been taught.

I turned to the patient.

“How can I help you today?”

For about ten seconds, she said nothing. Then, with her eyes still cast downward: “My
stomach hurts.”

Okay, pain. We had an algorithm for pain.

“Where is your pain?” The answer may give me the diagnosis.

Her answer? Another whisper: “Everywhere.”

What did that mean?

I did not know, but I went on to the next question in the pain workup. “On a scale of one
to ten, with one being the least and ten being the most, how would you rate your pain?”

Her answer? “Two.” Then she added, “It’s the worst pain I’ve had in my whole life.”

“A two? And it’s the worst pain you’ve ever experienced?”

She affirmed that it was.

I tried explaining the pain scale to her again. “Let me clarify this for you. A one would be
something really minor—for example, bumping your elbow. A five is something moderate, like a persistent headache. Ten is extreme pain. Imagine your finger got chopped off. That bad. Now that I’ve given you some examples, how would you rate your pain?”

She looked at me with apathetic eyes. “Two.”

I wanted to get to the bottom of this, but there was too much else to do. I had to move on.

Next was “Review of Systems,” in which I asked her if she were experiencing any other
symptoms.

“Are you having any dizziness?”

“Yes.”

“What about vision or hearing changes?”

“Yes.”

“Which one?”

“Both.”

“Both?”

“Yes.”

“I see … Headaches?”

“Yes.”

“Nasal congestion?”

“Yes.”

“Tremors?”

“Yes.”

“Seizures?”

“Yes.”

I covered the heart, the lungs, her bowel habits, the endocrine system, the muscles and
joints.

“Yes, yes, yes, yes, yes, yes.” Never once did she make eye contact.

I was supposed to then ask questions about substance use, sexual behavior, and mental
health. But I was so thrown off by her responses to the Review of Systems that I forgot. It was a
mistake, but I doubted it was a big one—I had a hunch that her answers would all be yesses.

The physical exam followed. I pulled the stethoscope out of my white coat pocket and
used my hands to warm the metallic diaphragm.

“Now I’m going to listen to your lungs,” I said.

I walked behind her, lifted her shirt, and placed the diaphragm on her back.

She jolted forward with a screeching expletive, followed by: “That’s too cold!”

I could feel the heat rising in my chest, but I tried to sound calm. “I’m so sorry. Let me
warm it up some more.” This time, I rubbed it with my hands for a full minute and, for extra
measure, blew my warm breath onto it.

I tried again, and this time, she did not flinch. I also managed to listen to her heart.

I then had her lie down so I could examine her abdomen. First, auscultation. Then gentle
palpation. Finally, firm palpation. At least, that was my plan.

The second I lay the stethoscope on her mid abdomen, she screamed and practically
jumped in the air. There was another expletive, an “Ouch!” and an emphatic gesture I’d never
seen before. She turned away from me and curled her body into a tight ball.

This time, I just stood there, watching her. I wondered what she would do next.

She did nothing. Eventually, the proctor said, “Five minutes remaining.”

I had no choice but to do a sloppy job with the neurological exam. I told her I needed her
to sit up so I could check her facial sensation, but she would not budge from that curled-up
position. So I went through the motions, “testing” just the side of the body I had access to. I
banged on her right knee in a (failed) attempt to check her patellar reflex. I rubbed my fingers
together in front of her right ear and asked if she could hear it. No response. I stroked her right
forearm with my finger and asked if she could feel it. Again, silence. I struck a tuning fork,
placed it on her wrist, and asked her if she could feel it vibrate. Nothing.

Then time was up. The proctor asked me for my diagnosis. I had no idea. I knew it was
wrong, but I guessed appendicitis.

“That is incorrect,” he said. “This patient had depression. You failed to elicit a mental
health history which would have led you to the diagnosis.”

He continued, saying something about how patients with depression can be
“challenging.” But his words were meaningless to me. After he spoke the word—“failed”—my
hearing shut down.

I left the room limp, pale, speechless.

But I had to go on. I closed my eyes for a couple of seconds, took a breath, and then
moved in front of the room with the second patient.

I knocked and went in.

This room was spacious. The proctor was sitting in a chair with his legs crossed, a legal
pad in his lap and a fountain pen in his right hand. The patient—male, older, obese—was
opposite him, licking his finger and turning the pages of a tattered magazine.

He said he was having episodes of chest pain. Thank goodness, I thought. This is classic
medicine. I could play out in my mind how this would go. Confidence returned.

Taking a history and the Review of Systems was easy. He said he had been experiencing
pain upon exertion, shortness of breath, and leg swelling.

But things fell apart when I tried to examine him. I mixed up the otoscope and the
ophthalmoscope. When I sorted them out and tried to look at the retina with the ophthalmoscope, all I could see was a fuzzy red dot. Taking his blood pressure also proved to be a problem. The sphygmomanometer was mounted on the wall in such a way that I had to contort my torso to see the mercury tube as I inflated the cuff. This so flustered me that I missed the moment the pulse disappeared and had to re-inflate the cuff four times. And then there was the neurological exam.

It went okay until I got to the knee reflexes. The first step was to find the right spot to hit
with the reflex hammer. After asking the patient to pull up his pant legs, I placed my hand on his right knee and began to probe with my fingers. Immediately I knew I was in trouble. Instead of bony landmarks, all I could feel was spongy, amorphous flesh. I pressed harder, and harder, and harder—until the patient yelped in pain.

So I had to guess. I took my reflex hammer out of my coat pocket and hovered it over
where I thought the patellar tendon was located. Then bam! Down came the hammer. Nothing. I tried again. Bam! Nothing. I tried again and again and again. Failure every single time.

I didn’t want to alarm the patient, so I said nothing and moved to the left knee. But it was
just as plump and doughy as the right. I gave it my all, but, once again, I was unable to elicit a
reflex.

By then, I was covered in sweat. I put my reflex hammer back in my pocket and tried to
collect my thoughts.

When I finally spoke, my voice was shaky. “This is very unusual, sir. Do you by chance
have a neurological deficit?”

He looked at me like I was the one with a neurologic deficit. “Nope. Never been told that
before.”

“I see. Well perhaps you’d benefit from seeing a neurologist who could better evaluate—”

The proctor interrupted. “You’re way off track. Be mindful of the chief complaint.”

This meant the chest pain, of course. I did the best I could to wrap up the physical exam
and then presented my assessment to the proctor. Chest pain, concern for coronary artery disease, maybe myocardial infarction, need to get an EKG, labs, chest X-ray, etc., etc.

This last part must have impressed the proctor because, despite it all, he passed me. All I
could figure is that he had been daydreaming.

On to the last patient.

Allen gave me a preview. “She’s a real sweetheart. You’ll have no trouble with this one.”

I entered the room. The patient was an “LOL”—doctor speak for “Little Old Lady.” She
was quite striking to look at, with her shiny white hair, soft-looking skin, and gentle brown eyes.

Given her age, I was prepared for cancer, osteoporosis, or chronic lung disease. What she
said when I asked her what was troubling her surprised me.

“Vaginal discharge, doctor. It’s green and has an … unpleasant odor.”

Malodorous vaginal discharge? Immediately my mind went to sexually transmitted
disease. While I was considering this, I realized that what was expected of me here was the
pelvic exam. The pelvic exam! It’s hard enough to do a pelvic exam on a young patient, but on
this sweet old lady who could have been my grandmother? And in front of the proctor? I cringed and felt my face flush.

But I was training to be a doctor. Quashing my fear, I pressed on.

The first part of the exam went okay. Then it was time to use the speculum. With my
gloves on, I removed it from its sealed package and covered it in lubricant. I put my left hand
into position, using my fingers to spread the labia. Using my right hand, I rotated the speculum
so that the blades were vertical and the screw faced sideways. I placed the blade tips at the
entrance of her vagina. Then in it went.

The insertion went fine. But when I squeezed the lever to open the blades, the speculum
screw dislodged. The vaginal walls collapsed. And this must have caused a build-up of pressure, for the screw then shot straight out of her and hit me in the forehead. Instant lightning bolt pain. I staggered back and crumpled to the floor.

The patient sprung up. “Oh heavens! Doctor, are you alright?”

The proctor rushed to my side, eyes wide open. She touched my arm and, in a quiet
voice, said, “That has never happened before. Let me take a look at you.” As she leaned forward, a delicate, fairy-like scent enveloped me, of green tea, wisteria, peony. She carefully pushed aside my bangs and spent several moments scrutinizing my forehead. She took out a penlight and shined it in my eyes to check my pupillary reflexes. She had me count to twenty and recite the ABCs. After helping me to my feet, she asked me to walk around the room to check my balance. During all of this, I couldn’t help but compare her level of expertise to my ineptness.

When she was satisfied that the injury was minor, she said, “We’ll conclude here.” She
thanked the patient and led me out into the hallway.

Once there, she looked at me for a few seconds without saying anything. Then, in a kind
voice, she said that she was sorry, she knew it wasn’t my fault, but that she was going to have to give me an “incomplete” grade—I would need to come back and attempt the pelvic exam again the following month. I felt myself deflate.

“But think of this as a test of your resilience. My best advice for medical students is to
not give up. You will encounter all sorts of hurdles throughout medical school, during your
internship and residency, and throughout your years of practice. The most successful physicians are the ones who make peace with the fact that they aren’t perfect, learn from their mistakes, and move on. Do this, and you will thrive.”

I smiled and thanked her, but what I was feeling was far from gratitude. As soon as she
released me, I left. No checking my total score. No comparing notes with my classmates. No
sampling the snacks they’d set out for us. I found the first available empty room—a janitor’s
closet—closed the door, sank to my knees, and began to cry.

When I finally felt composed enough to come out, the building was empty. I walked
alone through its shadowy, labyrinthine corridors. Just how much did I want to be a doctor
anyway? Was my best going to be good enough? Would I have to deal with horrible situations
like these again?

I didn’t have the answers.

Stepping outside, I was met with bright sunlight and blue sky. There was a park across
the street. I heard the sounds of children playing, and music: bombastic, up-tempo, rhapsodic
music, a song I knew and loved. As I made my way to my car, I found myself singing along,
quietly at first, but then boldly, assuredly. A kernel of hope began to shape within me. Maybe the proctor was right. I decided I would wait it out and see. One day at a time, I thought. One day at a time.

__________

Christine Benton Criswell is a writer and physician in San Antonio, Texas. Her work is featured in several journals, including Jimson Weed, The Headlight Review, The Writing Disorder, New Pop Lit, and The Opiate. In her spare time, she enjoys reading, practicing tai chi, and taking walks.

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